Family Health Exam 1 Flashcards
Acrocyanosis
Acrocyanosis” refers to cyanosis found in the extremities, particularly the palms of the hands and the soles of the feet. It can also be seen on the skin around the lips. Acrocyanosis is often normal in babies, as long as no cyanosis is present in the central part of the body.
Active Acquired Immunity
Active immunity is created by our own immune system when we are exposed to a potential disease-causing agent (i.e., pathogen).
Apgar Score
Score of 7-10 = within desired limits
Score of 4-6 = oxygen, suctioning, stimulate the baby, rub the baby’s back.
Score of 0-3 = full code / resuscitation
A = Activity (Muscle Tone) 0 = absent; 1 = flexed arms and legs; 2 = active
P= Pulse 0 = absent, 1 is <100bpm; 2 is >100 bpm
G = Grimace (reflex irritability) 0 = floppy; 1 = minimal response to stimulation; 2 = prompt response to stimulation
A = Appearance (skin color) 0 = blue or pale; 1 = pink body, blue extremities; 2 = pink
R = respiration 0 = absent; 1 = slow and irregular; 2 = vigorous cry
Barlow Maneuver
Baby is on its back
Palm is in the palm of the examiner
Thumb is on the medial aspect
fingers on the lateral aspect
Do the test one side at a time
Bring the leg inward (adduction) and push backwards (towards the bed).
This tests if the hip is sublaxable (can be easily dislocated of the acetabulum)
Ortolani Maneuver
Baby is on its back
Palm is in the palm of the examiner
Thumb is on the medial aspect
fingers on the lateral aspect
Do the test one side at a time
Bring the leg outward (abduction) and pull anteriorly (to the front).
This tests if the hip is coming out of the socket
Brazelton Neonatal Assessment Scale
Also called the Neonatal Behavioral Assessment Scale (NBAS)
It is a neurobehavioral assessment scale designed to describe the newborn’s responses to his/her new extrauterine environment and to document the contribution of the newborn infant to the development of the emerging parent-child relationship.
It is used to examine the effects of prematurity, low birthweight, undernutrition, and a range of pre-and perinatal risk factors, the effects of prenatal substance exposure, environmental toxins, temperament, neonatal behavior in different cultures, prediction studies, and studies of primate behavior.
Caput succedaneum
Caput succedaneum is swelling of the scalp in a newborn across the midline. It is most often brought on by pressure from the uterus or vaginal wall during a head-first (vertex) delivery. Swelling and bruising usually occur on the top of the scalp where the head first enters the cervix during birth.
Cephalohematoma
Cephalohematoma is a minor condition that occurs during the birth process. Pressure on the fetal head ruptures small blood vessels when the head is compressed against the maternal pelvis during labor or pressure from forceps or a vacuum extractor used to assist the birth.
Chemical conjunctivitis
When eye drops are given to newborns to help prevent a bacterial infection, the newborn’s eye(s) may become irritated. This may be diagnosed as chemical conjunctivitis. Symptoms of chemical conjunctivitis usually include mildly red eye(s) and some swelling of the eyelids.
Congenital dermal melanocytosis (Mongolian Spots)
The term congenital dermal melanocytosis refers to one or more birthmarks. They are flat blue or blue/grey spots with an irregular shape that commonly appear at birth or soon after. Congenital dermal melanocytosis are most common at the base of the spine, on the buttocks, back and shoulders.
Dubowitz / Ballard tool
The Ballard Score is used to assess gestational age / maturity. A lower Ballard Score indicates lower gestational age and vice versa.
Ballard’s score is most accurate when performed within the first 12-20 hours of life.
Six neuromuscular markers are assessed: posture, square window (degree of wrist flexion), arm recoil, popliteal angle (degree of knee flexion), scarf sign (ability to extend the infant’s arm across the chest past midline), and heal to ear extension.
Seven physical characteristics are also evaluated: skin, lanugo, plantar creases, breast, eye and ear, and genitals.
A normal pregnancy can range from 38-42 weeks, so this is a normal Ballard score. The full Ballard range is -10 to 50.
SGA babies
SGA = Small Gestational Weight –> at risk for chromosomal abnormalities, malformations, congenital infections like rubella and cytomegalovirus.
Would have a low Ballard score.
nursing interventions are to assure the baby is appropriately fed, prevent hypoglycemia with glucose monitoring and possibly glucose interventions; maintain the baby’s temperature; monitor serum hematocrit (normal is 45-65%), assess for possible infections.
LGA
LGA = Large Gestations Age
LGA babies are at risk for birth injuries due to their disproportionate size and might also have genetic or congenital disorders, frequently are male, and are also at risk for congenital heart disease “happy chubby blue male infant”
Nursing interventions are focused on observing for potential complications (particularly if the mom is diabetic) and management of birth injuries like a clavicle fracture, facial nerve injury, erb-duchenne palsy, klumpke paralysis, phrenetic nerve palsy, and potential skull fracture.
Epstein Pearls
Epstein pearls are small, harmless cysts that form in a newborn’s mouth during the early weeks and months of development. They contain keratin and usually go away within a few weeks. The bumps contain keratin, a protein that occurs naturally in human skin, hair, and nails.
Erb-Duchenne paralysis (Erb palsy)
Erb’s palsy or Erb–Duchenne palsy is a form of obstetric brachial plexus palsy. It occurs when there’s an injury to the brachial plexus, specifically the upper brachial plexus at birth. The injury can either stretch, rupture or avulse the roots of the plexus from the spinal cord.
Erythema toxicum neonatorum
Erythema toxicum neonatorum (ETN) is a skin condition in newborns. Usually, ETN looks similar to acne. Red patches or small, fluid-filled bumps (pustules) may form on the baby’s face, limbs or chest. ETN isn’t dangerous and usually goes away on its own.
Finnegan Neonatal Abstinence Scoring Tool (FNAST)
reviews CNS disturbances, metabolic/vasomotor/respiratory disturbances, GI disturbances to create an overall score to assess infants exposed in utero to psychoactive drugs like opioids/opiates.
Score of 8+ indicates need for pharmacologic therapy.
All opioid exposed infants should have continuous monitoring via a cardiorespiratory monitor or pulse oximetry due to the potential for respiratory depression.
Infants should be scored every 3 hours throughout their hospital stay, but might need to be evaluated more frequently.
Habituation
If left in the same environment, over time they become accustomed to their surroundings and pay less attention to them. This process is called habituation. However, the moment something new happens, infants are ready to pay attention again.
harlequin sign newborn
Harlequin colour change appears transiently in approximately 10% of healthy newborns.1 This distinctive phenomenon presents as a well-demarcated colour change, with one half of the body displaying erythema and the other half pallor. Usually occurring between two and five days of age, harlequin colour change has been seen as late as three weeks of age.2 The condition is benign, and the change of colour fades away in 30 seconds to 20 minutes. It may recur when the infant is placed on her or his side.
Jaundice
Jaundice in newborn babies is common and usually harmless. It causes yellowing of the skin and the whites of the eyes.
Bilirubin
Bilirubin levels indicate jaundice.
Normal ranges:
<8.0 mg/dL for <24 hrs
<12 mg/dL for <48 hrs
<15 mg/dL for <5 days
Pathological jaundice
bilirubin is elevated within the first 24 hours of life. This often results from blood incompatibility, sepsis, infections like rubella, toxoplasmosis, occult hemorrhage, and erythroblastosis fetalis.
Pathological jaundice requires immediate nursing intervention - start with feeding (feed but also poop out the dead RBCs), warming, and then phototherapy.
Coombs
Tests mom & baby Rh factor
If the mom has a negative Rh factor and the baby has a positive Rh factor, the mother’s body will trigger antibodies against the baby’s positive antigen. These antigens will then mix into the baby’s body, which can be life threatening for the baby since their own body will be attacking their blood.
Give Rhogam if mom is Rh- and baby is Rh+
Newborn Glucose
Used to identify the glucose levels of the baby.
Normal range: 40 - 150 mg/dL
Hypoglycemia in newborns
<40 mg/dL
Results from mothers with diabetes, prematurity, or cold stress.
Nursing intervention is feeding and warming with ongoing glucose monitoring. If needed, provide the baby with 0% oral dextrose gel and possible IV infusion of D10W.
Warming is very important and helping the baby conserve energy.
Lanugo
Lanugo is soft, fine hair covering a fetus while inside the uterus. It helps protect them and keeps them warm while they grow. Some newborns have lanugo covering their bodies at birth, especially if they’re born prematurely. Lanugo can develop in people with eating disorders or certain tumors.
Meconium toxicology
The infant’s first stool can be used to test for fetal drug exposure during pregnancy. Meconium is used because it’s easier and more reliable than urine collection, and it’s easier to test at commercial labs.
Molding
During a head first birth, pressure on the head caused by the tight birth canal may ‘mold’ the head into an oblong rather than round shape.
Neonatal transition
The transition from fetus to neonate is a critical time of physiological adaptation. While the majority of term infants complete this process in a smooth and organized fashion, some infants experience a delay in transition or exhibit symptoms of underlying disease.
Neutral thermal environment (NTE)
The neutral thermal environment (NTE) has been defined as maintenance of the infants’ temperature with a stable metabolic state along with minimal oxygen and energy expenditure. The NTE is best achieved when infants can maintain a core temperature at rest between 36.5°C and 37.5°C.
Nevus Flammeus
A port wine stain (nevus flammeus) is a permanent birthmark that usually appears on the face.
nevus vasculosus (strawberry mark)
A strawberry nevus is a clump of tiny blood vessels that forms under the skin. It causes a raised red skin growth that may be present at birth or develop during infancy. A hemangioma looks like a strawberry birthmark, but it’s actually a benign (noncancerous) tumor. You may also hear the term vascular birthmark.
The tumor often grows for the first year and then shrinks, usually without treatment. About 10% disappear by the child’s first birthday. Of the rest, 90% of hemangiomas fade away by a child’s 10th birthday.
New Ballard SCore
the Ballard Score expanded to extremely premature infants.
Neonatal Infant Pain Scale
Used in children <1 year of age, as they cannot verbalize their pain. NIPS uses body language: facial expression, breathing pattern, state of arousal.
Score <3 indicates pain or discomfort.
Orientation
The infant turns its head towards sounds.
Passive-acquired immunity
Passive immunity is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system. A newborn baby acquires passive immunity from its mother through the placenta.
Periodic breathing
A baby may breathe fast several times, then have a brief rest for less than 10 seconds, then breathe again.
Physiologic anemia of infancy
Birth to three months – The most common cause of anemia in young infants is “physiologic anemia,” which occurs at approximately six to nine weeks of age. Erythropoiesis decreases dramatically after birth as a result of increased tissue oxygenation, which reduces erythropoietin production
Physiologic jaundice
A newborn’s immature liver often can’t remove bilirubin quickly enough, causing an excess of bilirubin. Jaundice due to these normal newborn conditions is called physiologic jaundice, and it typically appears on the second or third day of life.
Thrush
Thrush occurs when too much of a yeast called Candida albicans grows in a baby’s mouth.
Vernix caseosa
Vernix caseosa is a white, creamy, naturally occurring biofilm covering the skin of the fetus during the last trimester of pregnancy. Vernix coating on the neonatal skin protects the newborn skin and facilitates extra-uterine adaptation of skin in the first postnatal week if not washed away after birth.
Expected finding.
Sudden infant death syndrome (SIDS)
Sudden infant death syndrome (SIDS) is the unexplained death, usually during sleep, of a seemingly healthy baby less than a year old. SIDS is sometimes known as crib death because the infants often die in their cribs.
Sudden unexpected infant death (SUID)
Sudden unexpected infant death (SUID) is a term used to describe the sudden and unexpected death of a baby less than 1 year old in which the cause was not obvious before investigation. These deaths often happen during sleep or in the baby’s sleep area.
Overlaying or accidental suffocation on a shared sleep surface. Accidental strangulation from unsafe surroundings. Wedging or entrapment. Immersion in water or drowning.
Expected Neonate Findings
Skin: pink or acrocyanosis, vernix, lanugo
Head: symmetrical, no bulging, but might see molding, caput (swelling crosses the suture line), cephalohematoma (blood b/w skull and periosteum that doesn’t cross the suture line)
Face: should be able to blink
Ears: should align with the outer canthus of eyes; not lower set (which indicates down syndrome)
Mouth: pink, moist, intact, epstein pearls
Neck/clavicle: no crepitus, no tenderness
Umbilical cord: Two Arteries & one vein (AVA)
Hips: expect equal leg length and symmetrical gluteal/thigh creases, no development dysplasia of the hip (Barlow and Ortolane manuevers)
Abnormal Neonate Findings
Skin: jaundice in the first 24 hrs; green or brown skin or under the nails
Ears: not lower set (which indicates down syndrome)
Neck/clavicle: injury
Hips: dysplasia of the hip (Barlow and Ortolane manuevers)
lbs to kg
1 kg = 2.2 lbs
Vitamin K
Intramuscular shot given within an hour of birth to prevent hemorrhage.
0.5mL – 1mL
Monitor for hemorrhage.
May monitor INR and PTT if necessary.
Monitor the skin for rashes.
While the baby will get some vitamin K from breast milk, it is usually low until they eat regular foods.
Vitamin K Deficiency Bleeds can be lethal and often have no warning signs.
Erythromycin
Eye ointment given within an hour of birth to prevent transmission of bacterial infections (specifically gonorrhea) from the mother to the newborn.
Hep B Vaccine
Whether the mother’s Hepatitis B surface antigen status is positive or negative, then the baby is given the hep B vaccine within 12 hours of birth
0.5mL IM within 12 hours of birth.
Series of 3 shots: within 12 hours of birth, at 1 month, and at 6 months.
Hep B Immunoglobulin (HBIG)
Given in addition to the Hep B Vaccine when the mom tests positive for Hep B.
Preferably given within the first 12 hours of birth.
The baby will be tested for the Hep B surface antigen and the antibody both at birth and at 9-12 months to confirm the course of treatment.
Oral Sucrose
Given to infants as analgesia for painful procedures.
24% Sucrose on the tongue results in slower heart beat and less crying during and after the procedure.
Babies 6 months and younger can have oral sucrose, and the RN can determine the need for this with your baby.
Mucus Secretion Suctioning
Expected.
It’s common to suction secretions from the mouth and the nose in order to clear the baby’s airway of mucus. This improves the baby’s ability to breathe.
Neonatal respiratory rate
Neonates generally have a range of 30-60 for a respiratory rate and have irregular breathing. It’s more important to look for other signs of struggling to breath, such as pulling in the ribs when taking a breath, grunting / wheezing / whistling sounds when breathing, flaring of the nares, bluish tone to the baby’s skin and lips, and if the breathing is both fast and shallow at the same time.
Neonatal Pulse Rate
The nurse’s assessment of the apical pulse would be within desired limits if the pulse is between 110-160 beats/min and somewhat irregular. However, a NICU intervention might be needed if the apical pulse is <110 or >160 beats/min with marked irregularities.
Phimosis
Concern.
It’s when the opening of the foreskin is too small to be pulled back over the glans. This is a concern because it might interfere with urinary, so the nurse would assess how well the baby can urinate.
Hypospadias
Hypospadias is when the urinary orifice is not positioned correctly; it is located on the ventral surface of the penis.
Infant Weight Range
The majority of infants weigh between 2500-4000g at birth. It is important to plot and document the weight so that the percentile weight of the baby can be established.
If the baby was <2500g, then he would be considered low birth weight (LBW).
Neonatal Breastfeeding
Newborn babies should feed every 2-3 hours or 8-14 times/day.
Hypotonia
Limp posture, extension of the extremities. This is a concern; the expected finding is active motion.
It might be caused by some form of brain damage, some disruption of nerves and muscles, infection, or lack of oxygen before the baby is born or immediately after.
If the baby is unable to swallow due to hypotonia, then the provider might decide to give the baby a feeding tube.
Pseudomenses
Pseudomenses is an expected or normal finding. It is a small amount of blood in the diaper because of the hormones that were ingested from the mother while in utero.
Depressed Anterior Fontanel
Concern.
A depressed anterior fontanel or sunken fontanel indicates that the baby doesn’t have enough food in her body, indicating dehydration.
The nurse would recommend increasing both the frequency and duration of breast feeding so that the baby can get more fluid and nutrients. If the mom can’t breastfeed enough for the baby, then supplementation with formula can be planned.
Tonic Neck Reflex Positive
Also called the Fencing Reflex; it’s normal.
High pitched cry
Concern - neuro injury of some kind.
When infants have an abnormally high-pitched cry, it is associated with something different with the infant’s metabolism and neurological development. The high pitch of the scream could be related to lower levels of activity in the baby’s vagal nerve. Massage therapies can stimulate vagal activities, improving the baby’s ingestion and helping them gain weight.
Dimple or Tuft of Hair on Spine
Concern.
A tuft of hair along the spine is one of the signs of spina bifida in babies. Spina bifida is a neural tube defect, when the posterior laminae of the vertebrae don’t close fully. This leaves an opening through which the spinal meninges and spinal cord might bulge through.
Causes of spina bifida include low folic acid intake, genetics, certain meds, women with diabetes, and obesity.
Clinical manifestations include paralysis, cognitive symptoms, abnormal brain development, and a birthmark/dimple/tuft of hair on the skin where the spinal defect is located.
Uneven gluteal folds
Concern - hip dysplasia
Uneven gluteal folds around a baby’s hips are a sign of developmental dysplasia of the hip – i.e. the hip pops out of the joint.
The nurse or provider might perform the Ortolani test, to confirm that the hip is dislocated. In this test, the clinician puts upward stress on the lateral thigh and with slow abduction, they will hear a clunk when the hip pops out of join.
The Barlow Maneuver is another test in which the clinician guides the baby’s hips into mild adduction and applies a slight forward pressure with the thumb. In an unstable hip, the femoral head will slip out.
Infants are usually treated with a soft brace that holds the hip joint in socket for several months.
Aldrete Score
The Aldrete score is a post-anesthesia discharge criteria that measures if the patient can move from Phase 1 recovery to Phase 2 recovery. It measures the patient’s O2 saturation, consciousness, circulation respirations, and activity.
Total score is 10.
>8 can move to Phase 2.
ASA Score
The ASA physical classification system is used to determine how healthy a patient is before surgery.
ASA 1 = healthy patient
ASA 2 = uncomplicated pregnancy, mild systemic disease, such as obesity or controlled diabetes.
ASA 3 = patient has 1+ severe systemic illnesses such as preeclampsia with severe features, gestational DM with complications, CAD, angina, or poorly controlled HTN
ASA 4 = life threatening illness such as pulmonary dysfunction
ASA 5 = patient is not expected to survive for more than 24hours unless surgery occurs.
ASA 6 = patient is brain-dead but may be an organ donor.
Coombs
The Coombs test checks the blood of the mother and the baby to determine whether or not they are Rh positive or negative.
If the mom is negative and the baby is positive, then administer RhoGAM, which is a vaccine that shields the mom’s blood from the antigens in the baby’s positive blood, which protects the baby.
Blood Type & Screen
Blood type and screen is a blood test that looks for the blood type of a mom and baby to determine if they are compatible.
Blood types are A, B, AB, or O
And all of these can have a combination of Rh+ or RH-.
AB+ is considered the universal recipient.
O- is considered the universal donor.
If the mother has Rh- and the baby has Rh+, then the mother’s blood will recognize the baby’s blood as foreign and develop antibodies that could attack the baby’s red blood cells.
Babies in this situation might need treatment for anemia or jaundice or other complications.
The mom might need the Rhogam vaccine during pregnancy.
Edinburgh Postpartum Depression Score (EPDS)
The EPDS is a 10-question screening tool that asks about the past 7 days and is used to determine whether or not a new mom might benefit from behavioral health follow up care.
13+ the new mom needs a follow up screening within 2-4 weeks. If the 2nd EPDS is 13+, then refer that mom to an appropriate health professional.
If Q10 has scores of 1, 2, or 3, then the woman and her baby (ies) safety would need to be assessed.
If Q3, Q4, or Q5 suggest symptoms of anxiety, a follow up visit or referral may also be appropriate.
Pain & PQRST
Pain is subjective, so we need some way to quantify it. Pain scores on a scale of 0-10 are a good way to communicate a person’s pain.
PQRST is a pneumonic for assessing pain.
P = provocation/ palliation
Q = quality / quantity
R = Region / Radiation
S = Severity Scale
T = timing
0-3 is mild pain
4-7 is moderate pain
8-10 is severe pain
PT / INR
PT = Prothrombin Time. It measures how long it takes for a clot to form in a blood sample. Prothrombin is a clotting factor that turns into thrombin with the assistance of clotting factor V.
Normal PT level is approximately 11-16 seconds.
INR = International Normalized Ratio. It’s calculated from the PT level and is used to monitor patients who are taking Warfarin.
Normal INR is <1.1, and between 2-3 if the patient is on warfarin.
The nurse should educate the patient about how to protect themselves from an injury such as using soft-bristled toothbrush and nonabrasive toothpaste, avoiding rectal suppositories or thermometers, limit straining with bowel movements or forceful nose blowing, be careful when using sharp objects like scissors and knives.
Platelets
Platelets are formed from bone marrow. When an injury occurs at a site, collagen releases activators and thrombocytes bind together. Platelets travel to the site, along with other clotting factors, adhere to the site, and increase stimulation for PLT until a clot is formed with fibrin.
100,000 – 450,000 / mcL
Elevated platelets can mean cancers, birth control, polycythemia vera
Decreased platelets (thrombocytopenia) could mean an autoimmune disease, meds, hemorrhage, leukemia
Rubella Screen
Rubella is a disease that can be very dangerous for a woman and her baby. The earlier the baby contracts rubella, the worse it is for the baby. Particularly in the first 12 weeks.
A rubella test detects antibodies that are made by the immune system to help kill the rubella virus.
7 IU/mL or less is negative.
8-9 IU/mL is equivocal, need to repeat testing in 10-14 days.
10 IU/mL or more is positive and indicates a current or previous exposure/immunization to rubella.
Common birth defects from congenital rubella syndrome (CRS) include deafness, cataracts, heart defects, intellectual disabilities, liver and spleen damage, LBW, and skin rash.
If the mother is infected within the 1st 20 weeks of pregnancy, she is likely to have miscarriage, stillbirth, or a baby with CRS.
LATCH score
LATCH is a measurement of how well the baby is attaching to the nipple and feeding.
L = latch,
A = audible swallowing,
T = type of nipple,
C = comfort,
H = hold
LATCH assessment is out of 10 points. 0-3 is poor; 4-7 is moderate, and 8-10 is good.
COVID vaccine
The COVID-19 vaccine is safe for pregnant and lactating women, and it is effective at preventing COVID-19 in people who are breastfeeding. Breastfeeding people who have the vaccine also pass along the antibodies in their breastmilk, which could help protect their babies.
Dose is a completed primary series & a booster.
NSAID (Ibuprofen)
Women with third- or fourth-degree perineal lacerations or who received an episiotomy can be given oral NSAIDs for their perineal pain in the first six hours postpartum.
Oral dosing is 200-400mg orally every 4-6 hours as needed.
The max is 1200 mg/day.
Fetal harm has been demonstrated if used during pregnancy, but NSAIDs are fine post-pregnancy. Contraindicated in pts with asthma or hypersensitivities to aspirin.
Oral Opioids
Propoxyphene + acetaminophen
Oxycodone + acetaminophen
Prescription opioids should be reserved for “breakthrough pain” in the postpartum period, after other analgesia (such as acetaminophen and NSAIDS) was not effective due to the risk for opioid use disorder and the low proportion of patients.
Duration of opioid use should be limited to the shortest reasonable course expected for treating acute pain.
The standard prescription should be no more than 30 5mg tablets of oxycodone.
Start with 5 mg Q3 hours PRN for pain, with an assessment after 3 doses.
Rh Immunoglobulin
Used when the Rh negative mom has an Rh positive baby.
In the 2nd Rh negative mom / Rh positive baby pregnancy, the mom’s immune system will recognize the baby’s Rh+ cells as foreign due to the encounter with the 1st pregnancy. This will trigger the production of Rh+ antibodies, which can cross the placenta and destroy the fetal Rh+ RBCs.
For antepartum prophylaxis, recommended dose is 300 mcg at approximately 28 weeks gestation.
If an Rh+ baby is born to an Rh- mother, 300mcg IM should be administered to the mother as soon as possible after delivery and usually no later than 72 hours after delivery.
MMR Vaccine
Rubella is dangerous for newborns, and this vaccine is a live vaccine. Since live vaccines aren’t generally given during pregnancy, it is recommended that the mom receive this vaccine immediately after the baby is born if the mom doesn’t have any immunity.
1st dose (0.5mL subQ) right after the baby is born and the 2nd dose at least 4 weeks later.
It is important to receive both doses before the mom becomes pregnant again.
TDAP Vaccine
Tdap vaccine presents pertussis, which is a bacterial respiratory illness and is also known as whooping cough. Whooping cough can cause apnea in infants and frequently leads to hospitalization, sometimes death.
1 dose (0.5ml subQ) and routine booster 5+ years after the last dose.
Single dose during each pregnancy, preferably during 27-36 weeks of gestation.
Flu Vaccine
Flue is a highly communicable disease that is spread by respiratory droplets. The risk for pregnant or post-partum women and their infants is significant.
Infants under the age of 6 months are not eligible for the flu vaccine and are the children with the highest incident of flu-associated hospitalizations and death.
The best protection available for infants is passive immunity from placental antibody transfer from their mother and high levels of annual influenza vaccination in their community.
Docusate
Many postpartum women experience tenderness in the perineal area or constipation from analgesics involved with the C section.
Taking a post-partum stool softener can help ease bowel movements.
100-300mg orally once daily or in divided doses.
PPH Medication Post Assessment
Assess lochia every 15 minutes for 1 hour, every 30 minutes for the next 2 hours, every 4 hours for 48 hours, then daily.
Monitor BP and Assess Hgb, Hct, and clotting factors as ordered.
Take vital signs every 5 minutes until stable, then every 15 minutes for 2 hours, then every 30 minutes until discharge from PP unit.
Evaluate fundus height and firmness of the uterus.
PPH Methergine
Used for postpartum hemorrhage treatment and prophylaxis. Contraindicated with hypertension.
0.2mg (1mL) IM following delivery of placenta or during the puerperium. May repeat every 2-4 hours as needed.
0.2mg (1mL) IM following delivery of the anterior shoulder, may deliver every 2-4 hours as needed
Mothers should wait 12+ hours before breastfeeding.
PPH Carboprost
Carboprost is used for postpartum hemorrhage that isn’t responsive to conventional management.
Carboprost is one of three prostaglandins available for elective abortions in the 2nd trimester.
Initial treatment of PP hemorrhage is 0.25mg IM every 15-90 minutes.
Max dosage is 2mg (8 doses)
For termination of pregnancy, 250 mcg IM followed by 250-500 mcg every 1.5-3.5 hours. MAX is 12 mg.
Carboprost can precipitate an asthma attack.
PPH Misoprostol
Misoprostol is used for treating and prophylaxis of postpartum hemorrhage, cervical ripening procedure / induction of labor, and termination of pregnancy.
For PP hemorrhage, the dosage is 800 mcg sublingually one time or 600-1000 mcg orally, sublingually, or rectally one time.
For prophylaxis of PP hemorrhage, the dosage is 400-600 mcg orally once after delivery, or 600-800 mcg orally/sublingually/rectally once.
For cervical ripening procedure, the dosage is 25mcg vaginally every 3-4 hours; max is 400 mcg.
Contraindicated in pregnant women and moms should avoid becoming pregnant for at least 1 month after using the med.
Also, some moms may have an increased risk of ulcers that are induced by NSAIDs or who have allergies to prostaglandins.
PPH Prostaglandin (Hemabate)
Given via IM for PPH
Contraindications are cardiac or pulmonary disease, asthma
PPH Oxytocin
Oxytocin is used for prophylaxis of hemorrhage during the third stage of labor or for treatment of postpartum hemorrhage (among other things like termination of pregnancy, augmentation of labor, and medical induction of labor).
For PPH prophylaxis, and for PPH, 10-40units can be added to an IV infusion.
The max concentration is 40 units / 1000mL solution.
Contraindicated if the fetus needs conversion prior to delivery, obstetrical emergencies, fetal distress, in situations where vaginal delivery is contraindicated.
Antibiotics During C Section
Routine antibiotics after c section reduced the risk of wound and womb infections in mothers.
A 48 hr course is prescribed.
The patient should be educated about how to control pain (ice packs), hygiene (sitz baths), about how to identify purulent or serosanguinous discharge and notify the HCP, and they should be educated about the stool softener.
They should also be educated that sex will likely be painful and to abstain until healed.
REEDA
Assesses the patients for signs and symptoms of infection:
R = redness, evaluating if there is excessive blood supply in the vessels. ICe packs can be applied to reduce redness and edema.
E = edema, caused by both injury and inflammation. High possibility of contamination of the wound due to the location. Sitz baths are recommended to ease pain, promote healing, and assure good hygeine.
E = ecchymosis / bruising
D = discharge thru the incision. Serosanguinous fluids or purulent fluids are a concern.
A = approximation of the skin at the point of the incision. Stool softeners should be prescribed to facilitate bowel movements.
Antianxiety and C Section
Preoperative anxiety can cause convulsion and severe hypotension immediately after spinal aneasthesia.
A single dose of antianxiety medication before caesarean delivery can lower the patient’s anxiety and have no adverse neonatal effects.
Diazepam 5mg is the preferred choice of drug.
Contraindications include patients with a history of substance abuse, respiratory depression, liver/kidney dysfunction due to an increased risk for adverse reactions or interactions with other medications.
Antiemetic
Nausea and vomiting are common side effects of anesthesia and pain meds that are used during and after C sections.
Anti-emetics may be used to treat the symptoms and improve the patient’s ability to recover.
10mg of metoclopramide or 0.5mg/kg or propofol.
Anesthesia
Most C section anesthesia is a localized or spinal anesthesia due to decreased risk for complications compared to general anesthesia. The goal is to achieve the balance of pain relief while maintaining consciousness and an increased rate of recovery post-operatively.
Assess the patient’s vital signs, LOC, O2 sat, and pain before / during / post administration of anesthesia.
Monitor the patient’s airway, breathing, and circulation before / during / post administrations.
Monitor for side effects, like nausea, vomiting, itching, respiratory depression, or allergic reactions.
Analgesics
Most women who go through a C section require significant pain control post-procedure.
Addressing pain is important for healing and for supporting the mother/baby bond.
Conduct a pain assessment every time the mom complains of pain so that the pain levels can be tracked and the care plan can be evaluated.
NSAID (Toradol)
Toradol / NSAIDs are used for pain management. Toradol works by inhibiting the production of prostaglandins, which are substances that cause pain and inflammation in the body.
In post-partum care, Toradol may be used in combination with other pain medications like acetaminophen or opioids.
Safe dose of toradol 30mg IV every 6 hours, for a maximum of 5 days.
Maximum daily dose of Toradol is 120mg/day
Epidural
An epidural during C sections provides pain relief to the lower body while letting the mom remain awake and conscious.
An anesthesiologist will insert a small catheter into the epidural space in the lower back, into which a local anesthetic and/or narcotics will be delivered.
Bicitra
Bicitra is used to reduce stomach acidity and to prevent complications due to aspiration during surgery.
30ml or 0.3M sodium citrate; one dose.
FHR Cat 1
Normal
Baseline rate = 110-160bpm
Moderate FHR Variability (6-25bpm)
Absent late or variable decelerations
Early decelerations may be present or absent
Accelerations may be present or absent
FHR Cat 2
Anything that isn’t a Cat 1 or a Cat3
Requires continued evaluations and close monitoring
- Bradycardia not accompanied by absent baseline variability
- Tachycardia
- Minimal baseline variability (<5 bpm)
- Absent baseline variability not accompanied by recurrent decelerations
- marked baseline variability
FHR Cat 3
Abnormal! Predictive of abnormal fetal acid-base status (usually acidosis). May require maternal position change, oxygen, IV bolus, and discontinuation of labor stimulation.
- sinusoidal pattern
- absent baseline variability and any of the following: recurrent late decelerations, recurrent variable decelerations, or bradycardia.
Rupture of membranes
Check fetal heart tones
confirm with ferning test
confirm with Nitrazine test (should turn blue)
Document time of rupture, amount, color, and odor
Prolonged ROM is anytime the ROM goes on for more than 24 hours prior to the onset of labor. Preterm ROM means that bacteria can travel up to the uterus and premature activation of some labor pathways.
It is associated with low SES, low BMI, smoking, UTI.
Bishop Score
The Bishop Score is a prelabor evaluation of the cervix. Higher scores indicate favorable cervix for labor.
The criteria are cervical dilation, cervical effacement, fetal station for 0-3 points and cervical consistency, and cervical position for 0-2 points.
A score of 8+ is considered favorable for induction.
McDonald’s Rule
McDonald’s rule = fundal height. Usually, fundal height is + or – 2 cms from the total weeks.
@12 weeks = fundal height @ the symphysis pubis
@ 16 weeks = halfway between the symphysis pubis and umbilicus
@ 20 weeks = at the umbilicus
@ 21-38 weeks = fundal height in cm should = gestation
Fetal Movement during labor
Assessing fetal activity is one of the things that a nurse should do during the intrapartum period. Hyperactivity may precede fetal hypoxia, while absence of activity may indicate fetal demise. It’s important to carefully assess the FHR.
First stage of labor
Onset of labor through full dilation (10 cm)
Latent phase
Active phase
Transition phase
First stage of labor - Latent Phase
Cervical dilation is 0-6cm
Contractions are 5-20 minutes, lasting 30-40 seconds
Patient Activity: may be at home or admitted to the hospital
Nursing Interventions: orient and assess mother, monitor maternal vital signs and fetal heart tones every 30-60 minutes.
Comfort: encourage ambulation, rocking, showers, tub, relaxation techniques
First stage of labor - Active phase
Cervical dilation is 0-8cm
Contractions are 2-5 minutes, lasting 40-60 seconds
Patient Activity: shower or tub, hands and knees, rocking, squatting
Nursing Interventions: encourage position changes, monitor maternal vital signs and fetal heart tones every 15-30 minutes.
Comfort: encourage relaxation, distraction, patterned breathing, massage
First stage of labor - Transition phase
Cervical dilation is 8-10cm
Contractions are 1.5-2minutes, lasting 60-90 seconds
Patient Activity: exhausted, may panic, become agitated and feel rectal pressure, nausea, trembling, increased bloody show
Nursing interventions: offer encouragement and support, empty bladder, monitor maternal vital signs and fetal heart tones every 5-15 minutes
Comfort: massage, position changes
First Stage of Labor Medications
systemic analgesia
Opioids
Sedatives
Benzodiazepines
H Receptor antagonists
Nerve block analgesia: epidural block, combined spinal-epidural
Second Stage of Labor
10 cm to birth of baby
Pushing!
Contractions are strong 1.5-3 minutes, lasting 60-90 seconds
Patient Activity: pushing with contractions, vary positions (squatting, sitting, hands and knees, lying supine or on her side)
Nursing Interventions: support maternal pushing effort, vary positions, monitor maternal vital signs and fetal heart tones every 5-15 minutes, warm compresses to the perineum with crowning, prepare equipment for birth, provide care to the newborn, dry baby and initiate skin to skin contact if stable.
Second Stage of Labor Medications
Nerve block analgesia and anesthesia:
local infiltration
pudendal block
Spinal block
Epidural block
Combined spinal-epidural
Third stage of labor
Delivery of the placenta
Duration - usually within 30 minutes
Signs of a separating placenta: gush of blood, lengthening of the cord, uterine contraction
Nursing Intervention: monitor and instruct mother to push. After expulsion of the placenta, monitor bleeding, assess fundus and examine placenta, administer medication as ordered, provide peri care and warm blankets, assist with bonding and breastfeeding.
Fourth stage of labor
Birth of the placenta through postpartum recovery period
Biophysical Profile (BPP Profile)
Used to identify a fetus at risk.
Typically performed after 28-32 weeks of pregnancy to evaluate the fetus’s health. A score <=4 means that you need to delivery right away. A score of 6 = some problems and testing might need to be completed, with a repeat test in 12-24 hours and consideration of delivery. A score of 8 = a good amniotic fluid volume.
Criteria are scored from 0-2 and include nonstress test, fetal breathing, fetal tone, body movement, amniotic fluid.
Meconium stained fluid
Concern – meconium staining increases the change that the baby aspirates meconium.
Meconium is a newborn’s first feces, which is typically passed in the first few days after birth. Although it doesn’t have any bacteria or odor, meconium can cause problems if a baby passes it while still in the uterus, where it will mix with amniotic fluid, and inhales (aspirates) the mixture before, during, or just after birth. This is called meconium aspiration, and it usually happens in babies born on time or post-term — after 42 weeks — as opposed to premature infants.
Passage of meconium before birth can be triggered by different stresses to the fetus. Usually this stress results from normal labor contractions, but sometimes it’s due to other causes, such as infection and poor blood or low oxygen flow to the fetus.
Leopold’s Maneuver
Determines fetal position, presentation, lie, and attitude after 24 weeks gestation. The mother needs to first empty her bladder. She should lie in supine position with knees slightly flexed.
Leopold’s 1st Maneuver
Determines fetal position - if the head is up or down. Find the head!
Place hands on the uterine fundus (top). The fetal head is round and hard. The fetal buttocks is soft and irregular.
Leopold’s 2nd Maneuver
Determines fetal back position.
Gently move hands down the side of the abdomen. The back is smooth and hard. The limbs feel irregular with movement.
Leopold’s 3rd Maneuver
Confirms presenting part
Place one hand above the symphysis. Grasp and confirm presenting part, note engagement of presenting part.
Leopold’s 4th Maneuver
Determine attitude of fetal head.
Facing the mother’s feet, place both hands on the lower abdomen. Note fetal brow or occiput.
Preeclampsia
Increase in BP after 20 weeks gestation, accompanied by proteinuria
Signs of worsening preeclampsia:
- BP of 160/110 on 2 occasions
- Proteinuria (5+ in 24 hours)
- Oliguria (<500mL of urine in 24hours)
- Visual changes
- severe headache
- Nausea and vomiting
- Hyperreflexia
- Pitting edema
- Epigastric pain
- Fetal growth restriction
HELLP Syndrome
Hemolysis of red blood cells
Elevated liver enzymes
Low platelets
Eclampsia
Occurrence of a seizure during antepartum, intrapartum, or postpartum period.
Care of eclampsia:
- Magnesium Sulfate IV bolus or sedative if needed
- Antihypertensive agents to reduce BP
- Position side lying
- Pad the side rails
- lung sounds
- O2 per face mask
- Evaluate fetal heart tones
Warning sign during pregnancy:
Spotting / bleeding
Miscarriage
Warning sign during pregnancy:
Painful urination
UTI
Warning sign during pregnancy:
persistent vomiting
hyperemesis
Warning sign during pregnancy:
Fever >38C
Infection
Warning sign during pregnancy:
Abdominal pain, shock
Ectopic pregnancy
Warning sign during pregnancy:
Regular uterine contractions
preterm labor
Warning sign during pregnancy:
Calf pain
DVT
Warning sign during pregnancy:
leaking vaginal fluid
Premature rupture of the membrane
Warning sign during pregnancy:
Absence of fetal movement
Fetal distress or demise
Warning sign during pregnancy:
spotting or bleeding
Placenta previa, placenta abruption
Warning sign during pregnancy:
elevated BP, proteinuria, severe headache, visual changes
Preeclampsia
VEAL CHOP MEAL
FHR Pattern & Cause table
V = variable deceleration; C = Cord compression; M = move the mom
E = early deceleration; H = head compression; E = Expect the baby!
A = Acceleration; O = okay; A = Ambulate, continue to observe
L = late deceleration; P = placental insufficiency; LION Pit (Left side; IV bolus; O2; Notify the provider; stop the Pitocyn)
Ferning
The Ferning or Fern test is when the nurse takes a sample of vaginal fluid and looks at it under the microscope, looking for fern patterns.
Ferning test has lower sensitivity than the Nitrazine strips.
Nitrazine Strip
Nitrazine paper is a type of pH paper that is used to confirm the presence of amniotic fluid.
The nurse takes a small sample of fluid from the cervix and places it on the nitrazine paper, which changes color from yellow to blue if the fluid is amniotic.
Prostaglandins
Decreased levels may contribute to hypertension. May also play a role in initiating labor.
Gravid
the state of being pregnant
Gravidity
the number of times a woman has been pregnant, irrespective of the outcome.
Nulligravida
A woman who has never been pregnant.
Primigravida
A woman who is pregnant for the first time.
multigravida
A woman who has been pregnant two or more times.
Para
the number of births at 20 weeks+, not the number of fetuses.
Multipara
A woman who has carried 2+ pregnancies over 20 weeks, regardless of the outcome.
Formula to estimate date of birth (EDB)
- Determine first day of the last, normal menstrual period (LMP)
- subtract 3 months and add 7 days.
Gravida (G)
The number of pregnancies; current pregnancy to be included in the count.
Term (T)
The number of term gestations delivered between 37 and 41 6/7 weeks.
Preterm (P)
The number of preterm pregnancies ending >20 weeks and <38 weeks.
Abortion (A)
The number of pregnancies ending before 20 weeks.
Living (L)
The number of her biological children currently living.
Four Ps of Labor and Birth
Passageway = birth canal
Passenger = fetus
Powers = contractions and pushing
Position = maternal
Mechanism of labor
Descent/engagement
Flexion
Internal rotation
Extension
External rotation
Expulsion
FHR: Baseline
Average FHR in 10 minutes.
normal = 110-160 bpm
Tachycardia = >160 bpm
Bradycardia = <110 bpm
FHR Baseline Variability
Fluctation of the baseline FHR
Absent = undetectable amplitude
Minimal = amplitude range <5 bpm
Moderate= amplitude range is 6-25 bpm
Marked = amplitude range is >25 bpm
FHR Variable Deceleration
Abrupt decrease in FHR <30 seconds, occurs randomly.
This is a concern. It is caused by cord compression.
FHR early deceleration
Gradual decrease in FHR >30 seconds, occuring at the same time as the uterine contraction.
This is not a concern; it is normal. It’s caused by head compression during the contraction.
FHR Accelerations
Sudden increase in FHR >15 bpm, lasts >15 seconds
These are not a concern.
FHR Late deceleration
Gradual decrease in FHR>30 seconds, occuring after the peak of the contraction.
This is a concern. It’s caused by placental insuffiency.
Episiotomy - 1st degree
Extends through the skin and superficial layers of the perineum
Episiotomy - 2nd degree
Extends through the perineal muscles
Episiotomy - 3rd degree
Extends through the anal sphincter muscles
Episiotomy - 4th degree
Extends through the anterior rectal wall
Hemorrhoid Care
Witch hazel, applied to the perineal area. This provides relief from the burning and itching of witch hazel.
POST BIRTH
If any of the following symptoms occur, call 911!!
P = Pain in the chest (Pulmonary embolism / cardiac problem)
O = obstructed breathing or SOB (Pulmonary embolism)
S = Seizures (eclampsia)
T = thoughts of hurting yourself or someone else (PPD)
Call your HCP:
B = bleeding, soaking a pad/hour, passing plum size clots (hemorrhage)
I = incision that is not healing, increased redness or pus (infection)
R = red or swollen leg that is painful or warm to touch (DVT)
T = Temp>100.4F (infection)
H = Headache that’s painful, RUQ abdominal pain, vision changes (Preeclampsia)
Thermoregulation
All newborns are at risk for heat loss through:
evaporation: as surface moisture converts to vapor
Conduction: with direct contact with a cooler surface
Convection: loss of heat from the body’s surface to coolerair
Radiation: heat loss from the body to a cooler surface that is close to the newborn but not touching.
Cord Care:
The cord will fall off in about 7-10 days
To promote drying, fold the diaper down to expose the cord to air.
Report redness, drainage, bleeding from the insertion site or foul odor.
Cord Care:
The cord will fall off in about 7-10 days
To promote drying, fold the diaper down to expose the cord to air.
Report redness, drainage, bleeding from the insertion site or foul odor.
Circumcision Care
Assess for bleeding every 30 minutes for 2 hours.
Apply petroleum jelly to decrease friction with diaper.
Document pain score & provide comfort measures.
Document post circumcision void. Clean area with warm water with diaper changes.
A yellow exudate will form on the glans of the penis on day 2/3. It’s normal.
Report excessive bleeding, redness, or swelling, difficulty urinating, or signs of infection.
Minimal Newborn Output
Day 1: 1 void; 1 stool - thick, tarry & black.
Day 2: 2 voids; 3 stools - thick, tarry, & black.
Day 3: 3 voids; 3 stools - soft, greenish to yellow
Day 4-7; 5-6 voids, 3 stools - mustard color, loose, seedy
Newborn warning signs to report
- trouble breathing (>60 RR or blue lips/fingernails)
- wheezing or grunting
- fewer than 6 wet diapers in 24 hours
- lethargy, floppiness, or jittery
- temp instability (normal = 97.7 - 99.7 or 36.5-37.5)
- dehydration (dry mucous membranes or sunken fontanel)
- yellow color in the whites of the eye or jaundice skin that gets worse 3 days after birth.
- excessive, inconsolable crying
- pus or red skin at the base of the umbilical cord stump.
- bleeding at the site of the circumcision.
Mother Hemoglobin
Normal = 12-15g/dL
Pregnancy = 10
PP = normal to decrease 1 gram
Mother Hematocrit
Normal = 35-57%
Pregnancy = slight decrease to 33 - 39%
PP = Normal to decrease 2-4%
White Blood Cells
Normal = 4500-11000mm3
Pregnancy = increase to 12000
PP = increase to 30,000
aPTT
20-36s
Mother Potassium Levels
3.5-5.3mEg/L
Mother Sodium Levels
135-145 mEq/L
Mother Chloride Levels
98-107 mEq/L
Bicarbonate (venous)
24-28 mEq/L
Mother Glucose Levels
70-100mb/dL
Mother HgA1c
4-5.6%
Mother BUN
6-20 mb/dL
(renal function study)
Mother Creatinine
0.2-1.0 mb/dL
(renal function study)
Baby Glucose
40-96 mg/dL
Baby Hemoglobin
14-20 b/dL
Baby Hematocrit
43-63%
Baby Platelets
150-350
Baby WBC
10-30
